Somatizing Patients: Part II. Practical Management
Am Fam Physician. 2000 Mar 1;61(5):1423-1428.
See related patient information handout on somatic illness, written by the authors of this article.
This is part II of a two-part article on somatization. Part I, “Practical Diagnosis,” appeared in the February 15 issue (Am Fam Physician 2000; 61:1073-8).
This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Somatization is the experiencing of physical symptoms in response to emotional distress. It is a common and costly disorder that is frustrating to patients and physicians. Successful treatment of somatization requires giving an acceptable explanation of the symptoms to the patient, avoiding unwarranted interventions and arranging brief but regular office visits so that the patient does not need to develop new symptoms in order to receive medical attention. Antidepressants may be helpful in many patients, as well as cognitive psychotherapy when patients are willing to participate in it. Typical problems in managing such patients can be addressed by relying on the continuity established through regular visits to the same primary care physician.
Patients with somatization experience emotional distress or difficult life situations as physical symptoms. This common and costly disorder is frustrating to patients and physicians.1 This article reviews management strategies (some of which have received empiric support through controlled studies) recommended by clinicians experienced in dealing with such patients.
The first principle of effective management is to understand the patient's suffering and develop a concerned attitude. From the standpoint of the physician, the symptoms may seem exaggerated and the worries irrational, but the patient's suffering is always real. Even in the clearest cases of organic pathology, suffering is poorly correlated with the extent of tissue damage.2 Suffering is always a subjective phenomenon. Patients may amplify normal body sensations and be locked into a role as the identified patient, unconsciously seeking to be treated as a sick person, but they still suffer from pain and limitation of functioning. Failure to acknowledge this suffering and disability may be interpreted by patients as trivializing, and it impairs the physician-patient alliance.
Successful approaches to somatization rely on providing an acceptable explanation of the symptoms to the patient, establishing reasonable treatment goals1 and arranging for brief but regularly scheduled office visits that help make it unnecessary for the patient to develop new symptoms in order to see a physician.3
Discussing the Diagnosis
The first opportunity to discuss the diagnosis occurs when the initial work-up has failed to identify organic pathology. This is a defining moment in the physician-patient relationship. The first challenge is describing the condition to the patient in a manner that avoids any reference to the ineffective “It's all in your head” idiom. In order to achieve this goal, physicians must understand that the concept of somatization is well beyond the grasp of the patient's rational mind and, for that matter, beyond medicine's usual way of understanding disease. With this in mind, physicians should be comfortable making a statement such as: “The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far.”
This statement acknowledges the patient's suffering and experience of disability. It provides reassurance by emphasizing that this is not a rare condition, yet acknowledges the limitations of treatment from the outset. Finally, it avoids rejection and, instead, emphasizes that the physician will be actively engaged in helping the patient function more effectively.
If the patient insists on receiving a name for the condition, it is often best to say that there are many names for the condition, none of which is completely satisfactory. Patients might be told that the terms “pain disorder” and “somatoform disorder” are sometimes used to refer to the condition but that the labels only hide our ignorance.
Patients often seem reassured when a specific name is given to the condition, such as “fibromyalgia,” “chronic fatigue syndrome” or “irritable bowel syndrome.” Such labels help them identify with the traditional disease model of their symptoms and reassures them that the physician is not thinking that it is “all in their head.” To the extent that labels facilitate the physician-patient relationship and help focus the patient's efforts toward functioning better, there is no harm in using them. In one study, 90 percent of patients with chronic fatigue reported that receiving the diagnosis was the most important factor in their treatment course.4 Even when patients do not meet the diagnostic criteria that have been proposed for these different conditions, the labels can sometimes be used nonspecifically. For example, a patient can be told “you have a variant of fibromyalgia” if the main complaints are related to pain and fatigue.
Scheduling Regular Visits
After this introduction, the treatment plan can be discussed. It consists of regularly scheduled, brief office visits (e.g., 15 minutes once a month). These visits allow patients to receive some of the attention they need without having to develop new symptoms to obtain it. The physician can stress the importance of following the patient closely to help deal with current symptoms and make sure that no new, life-threatening condition is developing.
The frequency of visits may be adjusted according to the severity of the patient's somatization. One goal is to progressively diminish and then stop emergency visits and telephone calls altogether as patients learn to rely more on the regularly scheduled visits. The typical frequency of visits for patients with disabling symptoms is every three to four weeks. Some patients require even shorter intervals. Such regular visits have been shown to significantly reduce the cost and chaos of caring for patients with somatization disorder without affecting patient satisfaction with their care.3
During these brief visits, the physician listens for any new symptoms, conducts a brief physical examination that helps rule out any new or worrisome condition and provides the patient with the important benefits of “laying on of hands.” The physician also begins to shift the focus away from the patient's physical symptoms to the psychosocial context that may be most affecting them. A time-honored opening that is comfortable for physician and patient is: “How have your symptoms interfered with your everyday life?”
It is important to ask open-ended questions rather than questions that can be answered with “yes,” “no” or another single word. Somatizing patients are always ready to discuss the way their symptoms are affecting their life. This question avoids the threatening suggestion that stress or other psychologic factors may be causing the symptoms. Yet it may lead to important information that links life circumstances with symptoms, especially when it is followed by gentle prompts such as: “Tell me more about your (boss, husband, children, girlfriend, etc.).”
The BATHE technique5,6 provides an excellent framework for exploration of psychosocial stressors (Table 1). This entire interaction may last less than five minutes and still provide useful information for the physician, as well as meaningful support to the patient. The same structure can often be used during subsequent visits. Variations develop naturally as the patient and physician become more comfortable with each other and with this aspect of their relationship.
TABLE 1. The BATHE Technique
The BATHE Technique
Background: “What is going on in your life?”
Affect: “How do you feel about it?”
Trouble: “What troubles you the most about that situation?”
Handle: “What helps you handle that?”
Empathy: “This is a tough situation to be in. Anybody would feel (down, stressed, etc.). Your reaction makes sense to me …”
Adapted with permission from Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care physician. 2d ed. Westport, Conn.: Praeger, 1993.
Other useful interventions during these regular visits include recommendations for anti-depressant medications, stress-management programs, lifestyle changes and benign medical treatments, as described below.
Pharmacologic Treatment of Comorbid Psychiatric Conditions
The psychiatric disorders associated with somatization, specifically anxiety and depression, respond well to pharmacologic treatment. However, especially with antidepressants, it is important to start with low dosages and to increase the dosage progressively to avoid side effects that may be present at the beginning of treatment and discourage the patient from continued use of the medication.
Although pharmacotherapy is often beneficial, it does not address the essential mechanisms of symptom amplification and the “need to be sick” that is associated with somatization.1 For this reason, pharmacotherapy can be thought of only as an adjunct to regular visits with the primary care physician.
Psychoeducation and Psychotherapy
Approaches derived from cognitive psychotherapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatizing patients.7–12 This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful. It then proceeds to challenge the patient's beliefs and maladaptive behaviors in a gentle and caring manner.
Some centers have established brief group therapy programs (eight to 16 sessions) specifically for treatment of somatizing patients that have been shown to be remarkably effective in improving function and reducing distress.8,13 The sessions combine general advice such as stress management, problem solving and social skills training with specific interventions targeted at the amplification and need-to-be-sick features of somatization.
Patients should be gently encouraged to pursue this type of treatment, individually or in a group format. To avoid the stigma often associated with mental health referrals, these treatment programs may be referred to as “stress management for patients with chronic illness.”
Interventions directed at reducing specific sources of stress are most helpful. Such interventions may include psychoeducational advice about dealing with marital conflict or more effective ways to handle relationships with children. Family system interventions that reinforce healthy family alliances may also help.
Some physical exercise is important, even in patients who believe themselves to be physically impaired. It prevents deconditioning, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. A minimum of three 20-minute exercise sessions per week is desirable.
In general, physicians should emphasize the importance of pleasurable private time. Beyond exercise, this may include yoga classes or meditation, bowling or nature walks, which, under the general title of ”stress management,” can be presented as necessary medical treatments.
A number of benign interventions may be helpful in patients with somatoform disorders without causing possible iatrogenic complications (Table 2). Benign interventions include hot and cold packs, bandages, canes, lotions, vitamins and nutritional supplements. In addition, complementary medicine approaches such as acupuncture, chiropractic massage therapy, biofeedback or homeopathy may have highly positive effects. These approaches do not challenge the patient's view of himself or herself as ill but provide a framework within which the patient learns to take responsibility for his or her own health. Even though there is no evidence to support the use of benign interventions in patients with somatization, these modalities are generally much safer than the diagnostic and surgical procedures that are often offered by conventional medicine with little rationale.
TABLE 2. Treatment of Somatizing Patients
Treatment of Somatizing Patients
Use one designated physician.
Schedule frequent, brief, regular visits not contingent on new complaints.
Allow “sick role;” focus on function rather than symptoms.
Explore psychosocial issues.
Prescribe benign treatments and enjoyment time.
Suggest “It's all in your head.”
Pursue invasive diagnostic tests, medications or surgical interventions without good indications.
Refer excessively to specialists.
Focus on the symptoms themselves.
Problems in Management
Several common problems can derail the course of treatment.
SETTING UNREALISTIC GOALS
In severe cases of somatoform disorder, symptoms are unlikely to resolve completely. If the unspoken goal of the treatment plan is to relieve the patient's illness, the physician and patient soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures. In fact, attempts to “take away the symptom” may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.
A more appropriate goal is to help the patient succeed in coping with the symptoms. The physician can help the patient tolerate uncertainty by demonstrating the ability to continue caring for the patient without finding a clear etiology for the symptoms. Treatment is successful if it keeps the patient out of the hospital and the emergency department, and if it reduces exposure to iatrogenic complications.
PRESENCE OF COMORBID MEDICAL CONDITIONS
Somatizing patients also develop organic diseases, especially common disorders such as osteoarthritis, coronary artery disease and cancer. Thus, preventive health measures and regular screenings must be integrated into the overall treatment plan. When organic pathology is identified, the patient's concerns or suffering may still seem exaggerated in relation to the degree of objective pathology. The principles of treatment outlined above should remain the mainstay of the physician-patient relationship while the organic pathology is addressed. Because subjective complaints remain unreliable in somatizing patients, treatment of the organic problem should be guided primarily by objective findings on physical examination or laboratory tests.
REQUESTS FOR DIAGNOSTIC STUDIES
Patients may challenge the physician's reassurance that no life-threatening condition is present. They may say,“How do you know that I don't have a brain tumor? You haven't done a brain scan.” Reminding patients that they will be followed with frequent and regular visits often reassures them that any problems will be identified early. Sometimes, performing laboratory tests becomes a “negotiating” process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.
REQUESTS FOR OPIATE ANALGESICS
Although patients with pain may request opiate analgesics, it is best to emphasize the benign treatments mentioned previously. Acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful if they are not contraindicated. Opiates have significant side effects such as constipation, sedation and impaired cognition. Addiction may also develop. Opiates will not cure the need to be sick that is often associated with somatization.14 In patients who require use of opiates for pain management, preparations with a slow onset of action and long half-lives should be used and preferably for short intervals. These preparations, such as the continuous-release forms of morphine sulfate or oxycodone, are less likely to be abused and have a lower street value.
FREQUENT TELEPHONE CALLS
Excessively frequent telephone calls may threaten the physician-patient relationship. To address this problem, the physician can emphasize his or her own feelings and needs (which cannot be challenged) rather than set limits on the patient's behavior (which may be perceived as arbitrary rules). A typical statement may be: “It is hard for me to give you the proper care and attention that you deserve when I find myself spending so much time on the telephone with so few positive results for you.”
It may then be appropriate to propose more frequent regular visits or to set an explicit limit on the number and length of calls, such as “I understand that there may be times when you feel you cannot wait for your next office visit. Maybe this means that we should increase the frequency of the visits,” or “I am comfortable with us having one or two 10-minute telephone calls between visits, but I am concerned when it gets beyond that. Can we agree on that limit?”
FREQUENT VISITS TO THE EMERGENCY DEPARTMENT
Visits to the emergency department often result in inconsistent care and mixed messages from physicians who are seeing the patient for the first time and may be alarmed by the patient's presentation. New iatrogenic complications may also be induced from unnecessary procedures or inappropriate admissions to the hospital. The understandable concern of emergency department physicians for undiagnosed organic pathology also reinforces the patient's impression that a life-threatening medical condition is present and can seriously impair the outpatient treatment plan.
Emergency department staff should agree to avoid repeating tests and inpatient admissions unless the patient presents with new objective findings. At the same time, the patient should be reminded that the regular ambulatory clinic visits are meant to take care of all medical needs. A shorter interval between visits can be negotiated, but it should be noted that the ambulatory clinic visits are expected to help avoid emergency department visits.
Unfortunately, because of the current nature of emergency department staffing, these goals may be difficult to achieve unless continuity and communication can be established between the emergency department and the outpatient office.
This article is based in part on a paper written by the first author and previously published as Servan-Schreiber D. Coping effectively with patients who somatize. Women's Health in Primary Care 1998;1: 435–47.
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